Current Surgical Treatment of Gastro-oesophageal Reflux Disease
Current Surgical Treatment of Gastro-oesophageal Reflux Disease
European Gastroenterology & Hepatology Review Volume 5 Issue 1
Published: October 2009
Published: October 2009
Abstract
Gastro-oesophageal reflux disease (GORD) is a disorder caused by lower oesophageal sphincter (LOS) dysfunction. Local anatomical abnormalities such as a hiatal hernia can predispose to this condition, leading to the characteristic hypotonia or shortening of the LOS. Smoking, alcohol, obesity and pregnancy also predispose patients to GORD. The most significant factor in the development of GORD is transient LOS relaxation (TLOSR). TLOSR typically lasts for 10–45 seconds and is unrelated to swallowing. Barium oesophagram, upper gastrointestinal endoscopy, pH monitoring and oesophageal manometry remain the key elements in the diagnostic work-up of GORD. Medical management of GORD is aimed at treating the predisposing factors using lifestyle modification (weight loss, smoking, alcohol cessation and avoidance of predisposing foods, etc.) and medications (i.e. antacids or proton pump inhibitors). Surgical intervention is aimed at restoration of LOS function (i.e. fundoplication). Recently, endoluminal therapy has been employed in the treatment of GORD with promising short-term results.
Keywords
Gastro-oesophageal reflux disease, Barrett’s oesophagus, Nissen fundoplication, transoral incisionless fundoplication, endoscopic antireflux procedure
Disclosure: The authors have no conflicts of interest to declare.
Received: 18 June 2009 Accepted: 8 July 2009
Correspondence: Ehab Akkary, Department of Surgery, School of Medicine, West Virginia University, PO Box 9238, Morgantown, WV 26506, US. E: eakkary@hsc.wvu.edu
Pathophysiology of Gastro-oesophageal Reflux Disease
When properly functioning, the lower oesophageal sphincter (LOS) is a physiological, rather than an anatomical, structure located slightly cephalad to the gastro-oesophageal junction that prevents reflux of gastric contents into the oesophagus.1 Hypotonia, shortening of the LOS and hiatal hernia predispose to gastro-oesophageal reflux disease (GORD). Sliding (type I) hiatal hernia is the most common hiatal hernia associated with this condition (see Figures 1 and 2). However, the presence of a hiatal hernia does not accurately reflect the occurrence of reflux disease.2 Other predisposing factors include obesity, smoking, alcohol intake and pregnancy.
Normal LOS resting pressures range from 10 to 30mmHg higher than the gastric pressure. A physiological short relaxation phase ranges from two to eight seconds. Transient LOS relaxation (TLOSR) lasts longer (10–45 seconds), is unrelated to swallowing and is the most significant factor in developing GORD. TLOSR is triggered by the belch reflex and occurs between three and eight times per hour in patients with GORD.3,4
Clinical Presentation
Upper mid-abdominal pain or ‘heartburn’ is the most common symptom of GORD. Dysphagia, regurgitation and globus are other gastrointestinal (GI) symptoms associated with GORD. The development of dysphagia may represent an oesophageal stricture. Endoscopic evaluation is mandatory to exclude the presence of a mechanical obstruction. The impact of acid reflux can extend beyond the GI tract and may affect the pulmonary system.
To register to view full article click here.
Keywords:
antireflux surgery, acid regurgitation, laparoscopic nissen fundoplication, Gastro-oesophageal reflux disease, Barrett’s oesophagus, Nissen fundoplication, transoral incisionless fundoplication, endoscopic antireflux procedure, proton pump inhibitors, h2 receptor antagonists, gastro oesophageal reflux acid reflux, hiatus hernia, gord, gord sysmptoms,
antireflux surgery, acid regurgitation, laparoscopic nissen fundoplication, Gastro-oesophageal reflux disease, Barrett’s oesophagus, Nissen fundoplication, transoral incisionless fundoplication, endoscopic antireflux procedure, proton pump inhibitors, h2 receptor antagonists, gastro oesophageal reflux acid reflux, hiatus hernia, gord, gord sysmptoms,
